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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 7 - <br /> (Complete in Triplicate) <br /> Permit No. .- <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -------------- --------- - ------ s ---. ----------CENSUS TRACT -------------- ------ <br /> Owner's Name ------------------------[46��)I�_-----��AQ4;;D ------------------------------------- - -------------------Phone._�35 --�L�S� <br /> Q - - <br /> Address ------------------------ ------------- -4�'���� f ---------------------- City A G`--------------------------------------------------------- t <br /> Contractor's Name ------------------------------ -----------------------------License # ---------:-------------- Phone ----------------------------- <br /> Installation will serve: Residence [�partment House-[] Commercial ❑Trailer Court ',❑ <br /> Motel ❑ Other -------------------------------------------- L <br /> x <br /> Number of living units:------/____ Number of bedrooms ____-----Garbage Grinder ___- Lot Size -----�t;_ ------------------ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private [}_ <br /> Character of soil to a depth of 3 feet Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam,E] <br /> Hardpan ❑ Adobe Fill Material _____.______If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit itted if c sewer is available within 200 fee t <br /> PACKAGE TREATMENT [ ] S Si` ----- -----I-------- ------ - --- --------- Liq id De -- -------- - ----- <br /> Ca cid Ty e - �ut_C�i ----- at ial _-- -- Na. Co partm �n <br /> Dis nce tot St. ell ---- ----------- --- ----------- ion - - ------------ Prop. ine ------------ --------- <br /> LEACHING <br /> -----LEACHING LINE { ] No, of Lines ________________________ Length of each line-------.- --------- - ------ Total Length _._________-___----___-_-__. <br /> 'D' Box ._._-�____-_ Type Filter Material ____________________Depth Filter Material --------------------------------- .......... <br /> Distance to nearest: Well ._'_________�__._____-_ <br /> SEEPAGE PIT [ ] Depth ------------ Diameter ---------------- Number ____________________________ Rock Filled Yes ❑. No ,0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance <br /> ------------------------- - - <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ........-._._........ <br /> . <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------3_________________----------------------------------- Date ----------------------------------I <br /> Septic Tank (Specify Requirements) A -r ,Y. <br /> Disposal Field (Specify Requirements) -APik------a �0------- '^- __ <br /> - ---------------------------------- <br /> ---------- ---- ------------------------------------- ------------------------------------------------=--------------------------------------------------------------- ---- ----------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- -- <br /> (Drow <br /> ----------------------------- - ---------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: I <br /> "I certify that in the performance of:the work for which this permit is issued, 1 shall not employ any person in such manner I <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----------------------------------------- -- - --------------------------------------------- Owner <br /> BY --- -- - -- -- ---- - I 1 Title - <br /> -owner) <br /> ------------------- --------------------------------- <br /> (if other than owner} <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- I 5 (`� DAT ---------------------- <br /> BUILDING PERMIT ISSUED ------------- -------------DA ----------------------------- ------ <br /> ADDITIONAL COMMENTS -------------- t------------------------------------------------------------------------------------------ /----------------=-------- - ---- <br /> ------------------------------------------------ <br /> i <br /> ----------------------------------------------------------------------- ------------------ - <br /> 4 <br /> 1 -- ---- - <br /> ------- <br /> Final Inspection by ' -------------------------------------------------- -------------3'6- --------- - ate --- --- <br /> J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M, <br /> i <br />